Introduction to Bone Marrow Transplantation
PRE-TRANSPLANT PROCESS and
BASIC HLA DISCUSSION
Dana Broadway RN, BSN, CHTC
BMT Nurse Coordinator
VCUHS Bone Marrow Transplant Program
Staff Nurse 1989-1995
Coordinator 1995 - Present
OBJECTIVES
• Describe the process and time line from the New
Patient Consult to BMT Admission
• Describe the process and time line from Related Donor
Identification to actual PBSC/BM donation
• Describe the importance of HLA typing and identify
important unrelated donor identification
characteristics
Patient Process
NP Consult
Induction/Salvage Chemotherapy
Restaging/Pre-testing
Second Consult
Stem Cell Collection
BMT Admission
New Patient Consult
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PA/NP
History and Physical
MD
Review disease process
Treatment options
Coordinator
Immediate specific needs identified - ?Social Work,
?Financial Coordinator
• Initial Plan
• Patient is discussed in weekly Clinical Conference
Induction/Salvage Chemotherapy
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Insurance
Donor Identification (tissue typing)
Unrelated donor search if necessary
Referring MD communication
Patient education
Housing/Environmental Issues
Caregiver Identification
Review of diagnostic slides
2 – 4 months depending on disease being treated
Restaging/Pre-testing
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CT/PET/MRI
BMBX
Labwork to evaluation disease
Organ Function (PFTs, MUGA/Echo, LFTs, KFTs, etc)
Infection evaluation (gyn, dental, cultures, CT scans)
Menses suppression
Some insurance companies require mammogram, PSA
screening, colonoscopy
• This phase can take up to 1 – 2 weeks
Formal Second Consult
• MD review test results
• MD consent (standard of care and/or clinical trial if eligible,
Advanced Medical Directive, NMDP consents)
• Meet with the rest of the BMT Team - Radiaton Oncology, Psych,
Social Work, Financial Coordinator)
• Obtain preauthorization from insurance company
• Meet with Coordinator to put a tentative plan on the calendar
• This phase can take up to 1 – 2 weeks
Stem Cell Collection
• Mobilization method
• Veinous access: line placement for majority of patients
• Apheresis or Bone Marrow Harvest
• Home Health for injections and/or line care
• Communication with apheresis/OR/BM Lab/Clinic
• This phase takes 1 – 3 weeks
BMT Admission
• Insurance pre-certification
• High dose chemotherapy regimen identified and communicated to
Pharmacy
• Final education session with patient
• Final planning session with patient
• Complete chart to Inpatient BMT Unit
Related Donor Process
HLA Typing
Donor Evaluation
Stem Cell/Bone Marrow Collection
HLA Typing
Donor Evaluation
• History & Physical
• Labwork (organ function, IDMs)
• CXR, EKG
• Risk Factor Assessment
• Social Work Evaluation
• Arm evaluation
• Education
• Consent
• This is all done in 1 day
Related Donor Collection
• Generally starts about a week after evaluation day
• Communication with apheresis/OR/BM Lab/Clinic
• PBSC (Peripheral Blood Stem Cell) Collection
– Neupogen given x 3 days
– Start apheresis (stem cell collection) on the 4th
– Usually collect in 1-3 days
• Bone Marrow Harvest
– Outpatient
HLA Basics
H = Human
L = Leukocyte
• White Cells
• Component of the immune system
• Recognizes self from non-self
A = Antigen – a substance that when introduced into the body stimulates
the production of an antibody. (ref: dictionary.com)
HLA Basics
• HLA plays an important role in identifying self from non-self –
VERY IMPORTANT IN TRANSPLANTATION
• Proteins on the outer surfaces on most cells of the body
• Inherited from our parents
• Located on chromosome 6
6 Different HLA Groups
A
Class
Class
I
II
B
C
DR
DQ
DP
• A, B, DR important in related donors
• A, B, C, DR important in unrelated donors
• Role of DQ, DP still under investigation
How you inherit DNA
Bb
MOM
DAD
B b
b b
Bb
bb
bb
How you inherit DNA
MOM
A01, B44, DR07
DAD
A02, B57, DR13
A04, B08, DR03 A05, B10, DR16
A01, B44, DR07
A01, B44, DR07
A02, B57, DR13
A02, B57, DR13
A04, B08, DR03
A05, B10, DR16
A04, B08, DR03
A05, B10, DR16
DNA Based HLA Typing
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Serologic: A01, B02, DR15
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Low Resolution: A01XX, B02XX, DR15XX
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Intermediate Resolution: Results are narrowed to 2 or more
alleles
A 01AB (0101, 0102)
B 02AC (0201, 0203)
DR 15MN (1503, 1505)
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High Resolution: Identifies the specific allele
A 0102
B 0103
DR 1503
What is a Match?
• Related Allogeneic BMTs:
– 6/6 A, B, DR high resolution match preferred
– 5/6 mismatch acceptable
• Unrelated Allogeneic BMTs:
– 8/8 A, B, C , DR high resolution match preferred
– 7/8 mismatch acceptable
– Current practice prefers A mismatch, over B, over C, over DR mismatches
• Cord Blood Transplants:
– 4/6 match or better
What Other Factors are Involved in
Unrelated Donor Identification?
• Weight of donor/cell count of cord
• Age
• Gender
• CMV status
• Parity
• Number of previous donations
• Race
• ABO Group
QUESTIONS?
• dbroadway@mcvh-vcu.edu
• 804-828-3554